TL;DR
A study of 399,500 Medicaid enrollees with acute low back pain found that starting with opioids or gabapentinoids was associated with higher subsequent rates of opioid use disorder or overdose than not starting those drugs. Chiropractic and physical therapy as initial treatments were associated with lower rates; the observational study cannot establish that treatment choices caused the differences.
A study of 399,500 Medicaid enrollees with newly diagnosed acute low back pain found that patients initially prescribed opioids or gabapentinoids had higher rates of later opioid use disorder or overdose than patients who did not start those drugs. The findings, reported in JAMA Network Open and based on claims data, add evidence relevant to longstanding guidance favoring nondrug options before prescription painkillers, but do not prove that the treatments caused the outcomes.
Researchers examined Medicaid records from 25 states for 2016 through 2019. The patients had a new acute low back pain diagnosis and no recent record of opioid use. Within a month of diagnosis, 21% received an opioid prescription and 5.8% received gabapentin or a similar drug. About 35% received a nondrug treatment, including chiropractic care, physical therapy or massage.
Compared with patients who did not start an opioid, those who began a course below 50 milligrams in morphine equivalents for at least seven days had a 105.2% higher relative likelihood of the combined outcome of opioid use disorder or overdose. The estimate for gabapentinoids was 101.6% higher. Starting opioids above 50 milligrams in morphine equivalents was associated with a 146.6% higher relative likelihood. These are relative comparisons, not percentage-point increases in the number of patients affected.
Starting with chiropractic care was associated with a 32.8% lower relative risk of the combined outcome, and starting with physical therapy with a 31.1% lower risk, compared with not starting those therapies. The study reported cumulative outcome rates of 1.4% at six months and 2.3% at 12 months after treatment initiation. Researchers combined diagnoses of opioid use disorder and overdose, so the results do not show how much each outcome contributed.
Implications for Initial Back-Pain Care
The findings matter because opioids remain a common first treatment for acute low back pain despite guidelines that have advised trying nonpharmacological care first. In this study, more than one in five patients received an opioid within a month of diagnosis. The results give clinicians and patients additional observational evidence to weigh when discussing initial care and possible longer-term harms.
The study does not establish that chiropractic or physical therapy prevents opioid use disorder or overdose, nor that the prescriptions themselves caused the higher rates. People offered different treatments may differ in health, pain severity, access to care or other factors that claims data cannot fully capture. The reported associations should not be read as individualized medical advice.
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Guidelines and Treatment Patterns
Guidelines have recommended for well over a decade that nondrug approaches be tried first for acute low back pain, according to the report. Yet earlier studies cited by the investigators found that 12% to 20% of privately insured or Medicaid patients received opioids for acute back pain in 2017-2018. Gabapentinoids, including gabapentin and pregabalin, have also been used as alternatives, although the report says evidence for their effectiveness in low back pain is poor.
The study population was relatively young, with a mean age of 39; 60% were women, and 98% had incomes below 138% of the federal poverty level. The analysis included Medicaid beneficiaries in states that accepted expanded Affordable Care Act eligibility. Those characteristics limit how readily the results can be applied to people with other insurance or different access to care.
““Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.””
— Kara E. Rudolph, PhD, MPH, MHS, of Columbia University, and colleagues, as quoted in the study report
physical therapy for lower back pain
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Limits of the Medicaid Records
This was an observational study of insurance records, not a trial assigning patients to treatments. It can identify associations but cannot determine whether a medication or nondrug therapy caused an outcome. The authors also focused on Medicaid enrollees, whose income and access to care may differ from those of the broader population.
Claims data may not capture over-the-counter medicines, drugs paid for out of pocket, or all care received outside the recorded system. The study combined opioid use disorder and overdose in its outcome measure, leaving unclear which accounted for more events. Although the overall cumulative rate reached 2.3% at 12 months, the report does not separate the absolute rates for each initial-treatment group here.
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How Clinicians May Use the Findings
The study adds to evidence clinicians can discuss when choosing initial treatment for acute low back pain, alongside a patient’s circumstances and existing clinical guidance. The researchers said medication may be considered after weighing benefits against longer-term risks and that opioid dose and duration should be minimized when prescribed.
The report does not announce a change to clinical guidelines or establish a new treatment rule. Further research could test whether the associations hold in other populations and clarify how much reflects treatment effects versus differences in patients’ health and access to nondrug care. No additional study milestone or guideline revision was specified in the report.
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Key Questions
What did the study find about opioids for acute back pain?
In Medicaid records, starting opioids was associated with higher later rates of the combined outcome of opioid use disorder or overdose than not starting an opioid. The association was higher for initial prescriptions above 50 milligrams in morphine equivalents than for lower-dose prescriptions.
Did the study prove that opioids caused those outcomes?
No. The analysis was observational and used insurance records, so it found associations rather than proving cause and effect. Differences in patients’ circumstances or access to care may also have influenced the results.
How were physical therapy and chiropractic care associated with outcomes?
Starting with physical therapy was associated with a 31.1% lower relative risk of the combined outcome, and starting with chiropractic care with a 32.8% lower relative risk, compared with not starting those therapies. These findings do not prove either treatment prevented opioid use disorder or overdose.
How common were opioid use disorder or overdose in the study?
Across the study population, the combined outcomes occurred at cumulative rates of 1.4% at six months and 2.3% at 12 months after treatment initiation. The report combined the two outcomes and did not show how much each contributed.
Do these results apply to everyone with acute back pain?
Not necessarily. The study covered Medicaid enrollees in 25 states, most of whom had low incomes. Results may not directly reflect people with other insurance, different access to care or different health circumstances.
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